VILLAGE OF PORT WASHINGTON NORTH

3 PLEASANT AVENUE

PORT WASHINGTON, NY 11050

(516) 883-5900

Permit No. ______Section: ______Block: ______Lot(s):______

Location: ______

Affidavit of Final Cost of Construction

Application for Certificate of Occupancy

State of New York

County of ______ss:

______, being duly sworn, deposes and says: that he/she is the applicant (or agent of the applicant) named in the Application for Building Permit dated ) ______, 20__ relating to construction or other work to be performed on, or in connection with, the premises located as indicated above, that the estimated cost stated in said application of the construction or other work described therein was ______Dollars ($______) and that the actual final cost of such construction or other work was ______dollars ($______).

Application is hereby made for the issuance of a Certificate of Occupancy/Completion for the structure on these premises. Applicant states that he has examined the approved plans and that to the best of his knowledge and belief, the structure has been erected in accordance therewith and in accordance with the applicable provision of the law.

Applicant further states that he/she was the (Note: Strike out items a, b or c, not applicable)

(a)  Licensed Architect, or (b) Professional Engineer, or (c) Superintendent of Construction who supervised the said construction or other work and that by reason of his experience he/she is qualified to supervise such work on the structure for which a Certificate of Occupancy is requested.

______(Applicant or Agent)

Sworn to before me

This ______day of ______, 20__ Filed cost $______

Permit Fee Paid $______

______Additional Fee $______

Notary Public

Costs for the work described in the Application for Building Permit include the cost of all of the construction and other work done in connection therewith, exclusive of the cost of the land. If the final cost is less than the estimated cost stated in the Application for Building Permit, no portion of the fee paid upon the filing of the application will be refunded.